Hashitoxicosis: An Uncommon Presentation of Autoimmune ...

[Pages:3]CLINICAL VIGNETTE

Proceedings of UCLA Healthcare -VOLUME 17 (2013)-

Hashitoxicosis: An Uncommon Presentation of Autoimmune Thyroid Disease:

By Brian S. Morris, MD

Case Report

The patient is a 10-year-old female with a history of GERD and urinary reflux who was referred by her pediatrician to an endocrinologist because of growth delay. Endocrine work-up was negative with a normal growth hormone stimulation test, IGF binding protein-3, and somatomedin-C (IGF-1). CBC was remarkable for a slight lymphocytosis with normal WBC, hemoglobin, and platelet count. MCV was slightly low at 77.0 fL (79.0 - 95.0 fL) with normal iron indices. TSH was normal at 1.7 mcIU/mL with a normal free T4 of 1.5 ng/dL. 25-hydroxy vitamin D was low at 17 ng/mL (30-80 ng/mL). Chromosomal analysis was performed and found to be normal XX with normal cytogenetics. Bone age was assessed with a left wrist x-ray and was consistent with normal skeletal maturity for chronologic age. The patient was followed over time with nutritional support and on routine follow-up was noted to have an elevated free T3 of 958 pg/dL (249-405 pg/dL) with a normal free T4 of 1.5 ng/dL (0.8-1.6 ng/dL) with a normal TSH of 1.1 mcIU/mL. Two days later, her labs were repeated and her free T3 was dramatically increased to 1358 pg/dL and her free T4 had increased to 1.9 ng/dL. Her TSH had decreased to 0.43 mcIU/mL. Antibody levels were positive for thyroid peroxidase antibodies at >600 ( ................
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